Exhibit 99.3
AFS
ADIRONDACK FINANCIAL
SERVICES BANCORP, INC.
Stock Offering Expires
12:00 Noon
Stock Center
52 North Main Street
Gloversville, N.Y. 12078
(518) 725-3660
STOCK ORDER FORM
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Number of Shares
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Number of Shares Purchase Price Total Payment Due
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The minimum number of shares that may be subscribed for is 25 and the maximum
number is 15,000 shares per individual or per account. The limit for any person
together with their associates or persons acting in concert in the
reorganization is 15,000 shares. Management has the discretion to increase or
decrease the purchase limit within regulations. Orders of $25,000 or more must
be paid by Gloversville Federal Savings and Loan Association account
withdrawals, certified funds, cashier's check or money order.
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Method of Payment
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/ / Enclosed is a check or money order made payable to Gloversville Federal
Savings and Loan Association for $__________.
Do not mail cash. Please take cash payment in
person to any Gloversville Federal Savings and
Loan Association office.
/ / I authorize Gloversville Federal Savings and Loan Association to withdraw
the indicated amounts from the following Gloversville Federal Savings and
Loan Association accounts, and understand that the amounts will not
otherwise be available for withdrawal.
Account Number Amount
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$
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$
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$
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$
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To withdraw from an account with check writing privileges, please write a
check. (Call the Stock Center for IRA transactions.)
There will be no penalty for early withdrawals of funds used to order stock.
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Purchaser Information
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/ / Check here if you are a director, officer or employee of Gloversville
Federal Savings and Loan Association or a member of their immediate
families.
/ / Check here if you were a depositor on the Eligibility Record Date,
September 30, 1996 or the Supplemental Eligibility Date, December 31, 1997
or a current depositor on - , 1998. If you check this box, please enter
all your account information for each of these dates on the back of this
form; (If you need additional space, please attach a separate sheet.)
/ / I am not acting in concert with any other persons purchasing stock in the
Reorganization nor are any of my associates purchasing stock.
/ / I am acting in concert with the following purchasers and/or the following
purchasers are my associates: __________, __________, __________.
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Stock Registration
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Please review the guidelines on the back of this form. Print the name(s) in
which you want the stock registered and the mailing address for the
registration. Names must appear exactly as on your account at Gloversville
Federal Savings and Loan Association if you are subscribing as an Eligible
Account Holder, Supplemental Account Holder or Current Depositor.
SUBSCRIPTION RIGHTS ARE NOT TRANSFERABLE.
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Form of ownership: Please check one.
/ / Individual / / Tenants in common / / Uniform Transfers to Minors Act
/ / Joint Tenants / / Corporation or partnership / / Uniform Gifts to Minors Act
/ / Other___________________ / / Fiduciary_____________________
please specify adoption date
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Name Social Security or Tax I.D. No.
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Name Evening Telephone
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Street Address Daytime Telephone
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City State Zip County of Residence
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NASD Affiliation
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Please read the NASD Affiliation section on the reverse side of this form.
Check if applicable and initial where indicated with *.
/ / Check here if you are a member of the NASD or a person associated with an
NASD member or a partner with a securities brokerage firm or a member of the
immediate family of any such person to whose support such person contributes
directly or indirectly or if you have an account in which an NASD member or
person associated with an NASD member has a beneficial interest. In accordance
with the conditions for an exception from the Interpretation, I agree (i) not
to sell, transfer or hypothecate this stock for a period of three months
following issuance and (ii) to report this subscription in writing to the
applicable NASD member I am associated with within one day of payment of the
stock.
* ------------------ (Initial )
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Acknowledgments
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To purchase stock in the Subscription Offering, this fully completed Stock
Order Form must be actually received by Gloversville Federal Savings and Loan
Association no later than 12:00 noon, New York Time on ____, 1998, unless
extended, otherwise this Stock Order Form and all subscription rights will be
void. Completed Stock Order Forms, together with the required payment or
withdrawal authorization and signed Certification, may be delivered to
Gloversville Federal Savings and Loan Association or may be mailed to the
address indicated on the enclosed business reply envelope. All rights
exercisable hereunder are not transferable and shares purchased upon exercise
of such rights must be purchased for the account of the person exercising such
rights. The undersigned certifies that this stock order is for my account only
and there is no agreement or understanding regarding the transfer of my
subscription rights or any further sales or transfer of these shares.
It is understood that this Stock Order Form will be accepted in accordance
with, and subject to, the terms and conditions of the Plan of conversion and
Stock Issuance of Gloversville Federal Savings and Loan Association described
in the accompanying prospectus, receipt of which is hereby acknowledged at
least 48 hours prior to delivery of this Stock Order Form to Gloversville
Federal Savings and Loan Association. If the minimum shares cannot be sold, all
orders will be canceled and funds received as payment will be returned
promptly.
The undersigned agrees that after receipt by Gloversville Federal Savings and
Loan Association this Stock Order Form may not be modified, withdrawn or
canceled (unless the Offering is not completed by ____, 1998 and if
Gloversville Federal Savings and Loan Association has been given authorization
to withdraw a specified amount from deposit accounts at Gloversville Federal
Savings and Loan Association as payment for shares, the amount authorized for
withdrawal shall not otherwise be available for withdrawal by the undersigned.
I ACKNOWLEDGE THAT THIS SECURITY IS NOT A DEPOSIT NOR AN ACCOUNT AND IS NOT
INSURED OR GUARANTEED BY THE SAIF, THE FDIC OR THE FEDERAL GOVERNMENT.
Under penalty of perjury, I certify that the Social Security or Tax ID Number
on this Stock Order Form is true, correct and complete and that I am not
subject to back-up withholding.
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Sign Below (You must also read and sign the Certification on the reverse side
to purchase stock). ---
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Sign and date the form. When purchasing as a custodian, corporate officer,
etc., include your full title. An additional signature is required only when
payment is by withdrawal from an account that requires more than one signature
to withdraw funds. YOUR ORDER WILL BE FILLED IN ACCORDANCE WITH THE PROVISIONS
OF THE PROSPECTUS. THIS ORDER IS NOT VALID IF NOT SIGNED.
If you need help completing this form, you may call the Stock Center at (518)
725-3660.
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x
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Authorized Signature Title (If Applicable) Date
x
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Authorized Signature Title (If Applicable) Date
x
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Name(s) on Accounts Account Number Name(s) on Accounts Account Number
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GUIDELINES FOR REGISTERING STOCK
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For reasons of clarity and standardization, the stock transfer industry
has developed uniform stock ownership registrations which we will use in
issuing your stock certificate. Common ownership registrations are explained
below. If you have any questions about how your Gloversville Federal Savings
and Loan Association stock should be registered, see your legal advisor.
To ensure correct registration, please follow the instructions for the
ownership you select:
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GENERAL INSTRUCTIONS:
o Include the first name, middle initial, and last name of each person listed.
Avoid the use of an initial in place of the first name.
o Do not use titles such as "Mr.", "Mrs.", "Dr.", etc.
o Omit words that do not affect ownership rights such as "special account",
"personal property", etc.
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INDIVIDUAL:
Instructions: Print the first name, middle initial, and last name of the person
in whose name the stock is to be registered. You may not list beneficiaries for
this ownership.
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JOINT TENANTS:
Joint Tenancy with Right of Survivorship identifies two or more persons as
owners of the stock. Upon the death of one of the owners, ownership
automatically passes to the surviving tenant(s).
Instructions: Print the first name, middle initial, and last name of each joint
tenant. You may not list beneficiaries for this ownership.
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TENANTS IN COMMON:
Tenants in Common identifies two or more persons as owners of the stock. Upon
the death of one co-tenant, ownership of the stock passes to the heirs of the
deceased co-tenant and the surviving co-tenant(s).
Instructions: Print the first name, middle initial, and last name of each
co-tenant. You may not list beneficiaries for this ownership.
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FIDUCIARIES:
Generally, fiduciary relationships (such as Conservatorship, Legal Trust,
Guardianship, etc.) are established under a form of trust agreement or are
pursuant to a court order. Without a legal document establishing a fiduciary
relationship, your stock may not be registered in a fiduciary capacity.
Instructions: On the first "NAME" line, print the first name, middle initial,
and last name of the fiduciary if the fiduciary is an individual. If the
fiduciary is a corporation, list the corporate title on the first "NAME" line.
Following the name, print the fiduciary "title" such as conservator, personal
representative, etc.
On the second "NAME" line, print either the name of the maker, donor or
testator or the name of the beneficiary. Following the name, indicate the type
of legal document establishing the fiduciary relationship (agreement, court
order, etc.)
In the blank above "Adoption Date", fill in the date of the document governing
the relationship. The date of the document need not be provided for a trust
created by a will.
EXAMPLE OF A FIDUCIARY REGISTRATION:
John D. Smith Trustee for Tom A. Smith Under Agreement Dated 6/6/74.
PLEASE NOTE THAT "TOTTEN TRUST" AND "PAYABLE ON DEATH" OWNERSHIPS MAY NOT BE
USED IN REGISTERING STOCK.
For example, stock cannot be registered as "John Doe Trustee for Jane Doe" or
"John Doe Payable on Death to Jane Doe."
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UNIFORM GIFTS TO MINORS ACT/UNIFORM TRANSFERS TO MINORS:
For New York residents and residents of many states, stock may be held in the
name of a custodian for the benefit of a minor under the Uniform Transfers to
Minors Act. For residents of some other states, stock may be held in a similar
type of ownership under the Uniform Gifts to Minors Act of the individual
states. For either ownership, the minor is the actual owner of the stock with
the adult custodian being responsible for the investment until the minor
reaches legal age.
Instructions: If you are a New York resident and wish to register stock in this
ownership, check "Uniform Transfers to Minors Act". For other states, see your
legal advisor if you are unsure about the correct registration of your stock.
On the first "NAME" line, print the first name, middle initial, and last name
of the custodian with the abbreviation "CUST" after the name.
Print the first name, middle initial, and last name of the minor on the second
"NAME" line.
Only one custodian and one minor may be designated.
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NASD AFFILIATION:
Please refer to the NASD AFFILIATION statement on the face of this form. If
applicable, initial where indicated and check the box. The National Association
of Securities Dealers, Inc. Interpretation With Respect to Free-Riding and
Withholding (the "Interpretation") restricts the sale of a "hot issue"
(securities that trade at a premium in the aftermarket) to NASD members,
persons associated with NASD members (i.e., an owner, director, officer,
partner, employee or agent of a NASD member) and certain members of their
families. Such persons are requested to indicate that they will comply with
certain conditions required for an exemption from the restrictions.
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CERTIFICATION
I/WE ACKNOWLEDGE THAT THIS SECURITY IS NOT A DEPOSIT OR AN ACCOUNT AND IS NOT
FEDERALLY INSURED, AND IS NOT GUARANTEED BY GLOVERSVILLE FEDERAL SAVINGS AND
LOAN ASSOCIATION OR BY THE FEDERAL GOVERNMENT.
If anyone asserts that this security is federally insured or guaranteed, or is
as safe as an insured deposit, I/we should call the Office of Thrift
Supervision Regional Director, Northeast Regional Office, at (201) 413-1000.
I/We further certify that before purchasing the common stock, par value $0.01
per share, of Adirondack Financial Services Bancorp, Inc. I/we received an
prospectus that contains disclosure concerning the nature of the security being
offered and describes the risks involved in the investment, including, among
other (1) ---------------------
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- --------------------- See "Risk Factors" on pages - through - of the Prospectus.
SIGNATURE:-------------------------- SIGNATURE:-------------------------------
PRINT NAME:------------------------- PRINT NAME:------------------------------